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BJPsych Bulletin
  • ISSN: 0955-6036
  • EISSN: 1472-1473
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New procedure for submitting letters

  • Patricia Casey and Jonathan Pimm
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eLetters

Latest Developments in ADHD

Dr Mukesh Kripalani , Frcpsych, Rcpsych
12 October 2018

Latest updates on ADHD 2018

Attention Deficit Hyperactivity Disorder (ADHD) and Attention Deficit Disorder (ADD) remains a controversial area for clinicians and patients across the world and the UK, despite evidence of effective treatment options and the likelihood of lives being changed for the better.

The National institute for health and care excellence (NICE) in the UK, have recommended interventions since 2006 and recently updated its latest guidance on diagnosis and management in March 2018 (https://www.nice.org.uk/guidance/ng87). They have made certain changes to past recommendations which include a suggestion of using Elvanse as first line in adult clients and introducing new safeguards in terms of specific cardiovascular assessment requirements in certain circumstances.

The prevalence of this condition varies across the world and one estimate suggest 5% of school-age children could suffer from the same with a significant cost burden to society (https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(18)30269-4/fulltext). With persistence of ADHD symptoms estimated in to adulthood to be about 60% (https://newsroom.wiley.com/press-release/journal-child-psychology-and-psychiatry/study-estimates-adhd-symptom-persistence-adult ), it is imperative the clients are supported and clinicians are familiar with the phenotype and able to appropriately manage the significant co-morbidity that exists with ADHD/ADD (http://adhd-institute.com/burden-of-adhd/epidemiology/comorbidities/ ).

In a recent article by Sudha Raman et al in the Lancet, trends in attention-deficit hyperactivity disorder medication use was explored in 13 countries and one Special Administrative Region (DOI: https://doi.org/10.1016/S2215-0366(18)30293-1). They noted the prevalence of ADHD medication use among children and adults increased over time in all countries and regions, but large variations in ADHD medication use in multiple regions exist. They recommended evidence-based guidelines need to be followed consistently in clinical practice and Samuele Cortese and Daniel Cogill (https://ebmh.bmj.com/content/early/2018/10/09/ebmental-2018-300050) suggesting no increase in prevalence rates if standard criteria are used.

In a major lancet article (https://doi.org/10.1016/S2215-0366(18)30269-4) Samuele Cortese and co, looked at the comparative efficacy and tolerability of medications for attention-deficit hyperactivity disorder in children, adolescents, and adults via a systematic review and network meta-analysis.

Summary:

I take this opportunity to highlight that pharmacological interventions are safe and is well tolerated across the world and use of stimulants is gradually increasing across the globe. The risks with stimulants medication are usually hyped up but it is exceptionally safe though the risk of diversion remains (https://www.sciencedirect.com/science/article/pii/S0890856709620815 ). The latter could be minimised easily by close supervision and use of long acting stimulants. It is important clinicians recognise this phenotype and direct clients to help as soon as possible as early intervention can change the trajectory of life (https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-99 ). The effect sizes clearly demonstrate benefits and the NICE guidelines seem to be consistent with latest meta analysis.

Of course there are co-morbid conditions co-existing which can mask the presence of ADHD and the fact of getting prescribed stimulants is difficult in certain situations to accept.

Hence instead of vilifying ADHD, we should encourage both clients and clinician to embrace the need for immediate treatment (biological, psychological and social) and hence improve outcomes for the future and help clients reach their full potential (https://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-10-99 )

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Conflict of interest: None declared

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Trials and Tribulations of S49 orders

Ilyas Mirza, Consultant Psychiatrist, Barnet Enfield and Haringey Mental Health NHS Trust
Mukesh Kripalani, Consultant Psychiatrist, Barnet Enfield and Haringey Mental Health NHS Trust
12 October 2018

The Mental Capacity Act, 2005 (MCA, 2005) is an Act of the Parliament, applying to England and Wales,that provides a legal framework for acting and making decisions on behalf of adults who lack the capacity to make particular decisions for themselves (MCA, 2005). Under section 49 (pilot order) of the MCA 2005, launched in 2016, the Court of Protection can order reports from NHS health bodies and local authorities, when it is considering any question relating to someone who may lack capacity and the report must deal with ‘such matters as the court may direct’. This change has caused significant ethical challenges for psychiatrists.

With regard to professional implications, Section 49 reports require an opinion, which according to the British Medical Association (BMA) and the General Medical Council (GMC) guidance this falls under expert witness work. The recent Pool Judgement is a reminder that the GMC is likely to consider fitness to practice is impaired if a doctor acts outside what is considered their scope of work (Pool v General Medical Council[2014]). The order is usually accompanied by an instruction letter containing legal precedents and a bundle sometimes containing conflicting assessments. Responding to such instructions require medico-legal training and experience in giving opinions to complex questions such as capacity to consent to sex, or consent to drink. We would argue that there is blurring of boundaries between expert and professional witness. There is a need to clarify what legal safeguards that are in place for the author of Section 49 reports, if their opinion is challenged, as it was in the Pool case.

In relation to patient care, the introduction of an automatic right to a medico-legal report, which was previously funded from elsewhere has shifted the cost on to the NHS. Given mental health services are still block funded; more work without additional funding leads to dilution of quality of care elsewhere in the system, hence affecting patient care. Lack of parity of esteem between physical and mental health funding makes this work an onerous burden. Increased workload without remuneration has an adverse effect on staff morale, thereby influencing recruitment and retention within an already struggling NHS.

There is an urgent need to quantify impact on these orders on services. The Royal College of Psychiatrists, working together with NHS England and the BMA, need to define medico legal work could be safely done within existing resource. Moreover, the BMA, GMC, the College and NHS Employers need resolve the discrepancy between what is considered expert witness work by regulatory bodies, being framed as normal NHS work by the Court of Protection (GMC, 2013). Legal safeguards need to be in place if NHS professionals become subject to legal challenge e.g. from an aggrieved solicitor. Consideration needs to be given to a fresh legal challenge if it is evident that this pilot order is affecting patient care.



References

Court of Protection Transparency Pilot: Case management S.49 pilots extension. 27th July 2017. Courts and Tribunal Judiciary

https://www.judiciary.uk/publications/transparency-pilot-case-management-s-49-pilots-extension/

General Medical Council (2013) Good medical practice London, GMC

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/acting-as-a-witness/acting-as-a-witness-in-legal-proceedings

Mental Capacity Act (2005) Code of Practice (2007) London: TSO.

https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice

Pool v General Medical Council(2014) EWHC 3791 Admin.

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Conflict of interest: None declared

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Choose Psychiatry, Continue Psychiatry

Andrew Howe, ST 4 in General Adult Psychiatry, South London and Maudsley NHS Foundation Trust
Vivienne Curtis, Consultant Psychiatrist
13 September 2018

Could improving oncall experience be the key to trainee retention?

Alongside encouragement to “Choose Psychiatry” we need to consider retention and “Continuing Psychiatry”. A recent survey by the Royal College 1 found that management on-call work was affecting morale so much that some trainees considered resignation. The same report commented on a high attrition rate between core and higher training, citing on call issues as a factor. Out of hours work is a challenging part of working in healthcare. Unsocial working hours can put a strain on the work life balance2, particularly with those who have families.3 The recent junior doctor strikes and new contract highlighted the value junior doctors place on appropriate management of on call work4 and GMC NTS results often highlight difficulties with out of hors working. With psychiatry recruitment in its present state and the concerted effort to increase applications to training via “Choose Psychiatry”, the nature of the on call experience may be the key to ensuring trainee retention. It is important, therefore, to ensure that experience on call is positive, supported and reflects training goals. We would suggest that the involvement of junior doctors in service design and restructure helps to secure this.

This approach was taken within our trust (South London and Maudsley NHS Foundation Trust) during the creation of a new service, the Centralised Place of Safety. This six-bedded unit was opened in June 2017. It is staffed by a dedicated MDT 24 hours and seven days a week. It accepts section 136/135 patients as part of the South London Crisis care pathway. Given its out of hours operation, an on-call medical staffing rota had to be created. The trust involved junior doctors in this process in collaborative way, through discussion with trainee committees and representatives to ensure their educational needs were met. An emphasis was put on face to face supervision by higher trainees with core trainees. Core trainees also had a clearly defined role within the MDT. A subsequent survey of trainees found that they preferred their on-call work in the place of safety compared to other locations5. A quote from the survey of particular note was “I would not want to qualify as a registrar without having had such experience’.

Choice of training scheme is multifactorial and improving on call experience maybe a small but important factor. We feel our service and its design process represent a good example of how to meet trainees needs and, thus, reinforces the need for consideration of trainee experience when planning out of hours rotas. We would argue that retention needs to be prioritised as much as recruitment if the gains of the “Choose Psychiatry” campaign are to be maintained.

1. Till A, Milward K, Tovey M, et al. Supported and Valued? A trainee-led review into morale and training within psychiatry. London, 2017.

2. Karhula K, Puttonen S, Ropponen A, et al. Objective working hour characteristics and work–life conflict among hospital employees in the Finnish public sector study. Chronobiol Int 2017; 34: 876–885.

3. Tucker P, Brown M, Dahlgren A, et al. The impact of junior doctors’ worktime arrangements on their fatigue and well-being. Scand J Work Env Heal 2010; 36: 458–465.

4. Tucker P, Byrne A. The new junior doctors’ contract: an occupational health and safety perspective. Occup Med (Chic Ill) 2016; 66: 686–688.

5. Howe A, Curtis V. What is the educational benefit of being on call ? A review of the on-call experience of psychiatry trainees in a new health based Place of Safety. In: Royal College of Psychiatrists International Congress. Brimingham, 2018.

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Conflict of interest: None declared

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Acceptability of receiving physical health investigations in the Clozapine clinic: a qualitative analysis of patients and healthcare professionals

Jason Hancock, ST7 Psychiatry/ Honorary Clinical Lecturer, Devon Partnership Trust
Chris Dickens, Professor of Psychological medicine, University of Exeter
Julia Frost, Senior Lecturer in Health Services Research, University of Exeter
13 September 2018

Early identification of physical health co-morbidities for people with serious mental illness is an important aim within the Mental Health Taskforce’s five year forward view for mental health[1]. In an attempt to achieve this a number of physical health ‘clinics’ have been developed within the secondary care mental health setting[2]. However there remains a lack of clear evidence regarding how to best structure such services[3] and it is unclear if patients and healthcare professionals (HCPs) find receiving physical health monitoring and investigations in this setting acceptable[2].

Following patient involvement sessions and meetings with local clinical stakeholders, we incorporated basic annual physical health monitoring and investigations (including blood tests and ECGs) into an established secondary care Clozapine community clinic. This intervention was initiated in September 2015 and over the first year offered to 52 out of 80 patients attending the clinic.

We undertook a qualitative study to elicit views from patients and HCPs regarding the acceptability of this intervention. We approached patients who had been exposed to the intervention over the previous year, and HCPs with first-hand experience of the intervention including medical and non-medical staff from the primary and secondary care setting.

Interview schedules were developed by the study team with input from patients attending the clinic. The lead author (JH) undertook 12 semi-structured qualitative interviews between November and December 2016 interviewing 4 patients and 8 HCPs. Interviews lasted between 12 and 30 minutes and were recorded, transcribed verbatim and analysed using the framework approach.

All of those interviewed described the intervention as acceptable. A number of key themes appeared to be underpinning this view. This included HCP perception that the intervention allowed more holistic care. This was particularly the case for secondary care nursing staff:

‘…as much as it is tiring and very busy, you feel that you are doing a bit more for people ... so, the more we focus on physical health it can affect their mental health’ (secondary care nurse).

HCPs also perceived that acceptability was influenced by the strength of existing relationships between patients and secondary HCPs. This view was shared by patients:

‘It’s you know, a personal service….....there's changes I need to make, so they just try and keep me in a positive frame of mind for it, which is appreciated because I need all the help I can get’ (patient).

However HCP in particular raised several concerns regarding the intervention. This included a concern that poor communication between primary and secondary care could result in duplicated investigations:

‘We get, you know, tens of results every day, and the last thing you want if you've already done the HbA1c, err, say a month ago is another HbA1c from the Clozapine clinic (laughs)’ (GP).

Finally a concern was also raised that there remains unclear professional accountability regarding who ultimately hold responsibility for acting upon those investigations requested:

‘I guess I was kind of trained with the idea that if you request a result you act on the result. But I guess perhaps, err, needs to just be tightened up a bit, is ... is ... is still the kind of who acts on the results, how do we know someone's acted on the result’ (Psychiatrist).

While it may be possible to develop an intervention to bring physical health monitoring and basic investigations into the secondary care mental health setting that is acceptable to patients and HCPs further modifications to this model are required. This includes a need to better develop systems to share clinical information and reduce the risk of duplicated investigations, and procedures to ensure consistent and timely interpretation of physical health investigations. In time improved commissioning of physical health services for people with mental illness would provide clarity regarding the clinical roles of primary and secondary care and to determine where financial responsibility for this care lies.

This research was approved by the South West - Exeter NHS Research Ethics Committee (16/SW/0265). Consent was obtained from all participants prior to interviews being conducted. This study was undertaken as part of an Academic Clinical Fellowship for JH funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. Funding for the transcription of interviews was provided by Devon Partnership Trust.

1. The Mental Health Taskforce. The Five Year Forward View For Mental Health. The Mental Health Taskforce, 2016. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf (accessed 19 Jul 2017).

2. NHS England. Improving the physical health of people with serious mental illness: a practical toolkit. NHS England, 2016. Available at: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/05/serious-mental-hlth-toolkit-may16.pdf (accessed 19 Jul 2017).

3. Tosh G, Clifton A, Xia J, White MM. Physical health care monitoring for people with serious mental illness. Cochrane Database of Syst Rev 2014. doi:10.1002/14651858.CD008298.pub3.

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Conflict of interest: None declared

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Physician Associate Student Attitudes to Psychiatry: evaluation of a three week mental health clinical rotation

Helen Hargreaves, ST4 Psychiatry, Northumberland, Tyne and Wear NHS Foundation Trust
13 September 2018

Physician Associates (PAs) are healthcare professionals with a generalist medical education. UK numbers are currently small and opinions regarding their suitability for mental health specialist services are mixed. However, they are destined to change the NHS workforce over the coming years and their role within mental health workforce planning and in the delivery of care to patients with mental illness warrants further consideration.

Negative attitudes towards mental health patients are identified as some of the background factors affecting speciality recruitment (1) and denigration of the speciality. It also affects communication with patients (2), not only potentially serving as a barrier to the access and quality of care that patients receive but also to the help-seeking behaviours of healthcare professionals themselves (3). Mental Health (MH) clinical placements provide educational experience and enable patient contact, which have been shown to promote positive attitudes towards psychiatric services and patients (4).

At Northumberland, Tyne and Wear NHS Foundation Trust we have recently hosted our first PA MH clinical rotation. The impact of this rotation on attitudes was evaluated using the Attitudes to Psychiatry (ATP) scale (5). This is a 30 item validated scale designed to measure medical student attitudes to psychiatry. We adapted the scale to consider only 10 items and amended some terminology to relate to PA students. It was offered to all students (n=11) at their induction day and at the end of their rotation. Students marked on a Likert scale how strongly they agreed or disagreed with the following statements: 1.Psychiatric illnesses need attention; 2.Psychiatric patients are interesting; 3.Psychiatry is a respected branch of medicine; 4.Psychiatry is based on scientific evidence; 5.It is rewarding to try and unravel the cause of psychiatric illness; 6.Psychiatry makes little use of medical training; 7.Psychiatry is an exciting specialty; 8.People working in psychiatry get less satisfaction from their work than other specialists; 9.I would consider working in psychiatry; 10.Skills and knowledge in psychiatry are important for all medical professionals.

Desirable responses increased for 9 out of 10 statements, demonstrating a strong favourable impact on PA student attitude and advocating the role of MH clinical rotations within the PA course. Statements relating to psychiatry being exciting and considering working in psychiatry demonstrated the greatest increase (27%). Unfortunately an increase in undesirable attitudes was also noted concerning psychiatry making use of medical training, drawing attention to the potential for an unfavourable impact here.

Overall, our results demonstrated the potential positive impact of a MH clinical rotation on PA student attitudes and supports its role within their clinical training. Even within a generalist setting, their more positive attitudes will go some way in ‘Banning the Bash’ and tackling the inequality of care for patients with mental illness. The potential to favourably influence attitudes and recruitment also serves as a reminder for all psychiatric healthcare professionals to assume responsibility and to participate positively in opportunities for contact with PA students, or indeed students from other healthcare disciplines, to realise this potential benefit to patient care.

References

1. Brockington, I. Mumford, D. Recruitment into psychiatry. The British Journal of Psychiatry 2002; 180:307-312.

2. Novack, DH. Suchman, AL. Clark, W. Epstein, RM. Najberg, E. Kaplan, C. Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient. JAMA 1997; 278(6):502-9.

3. Knaak, S. Mantler, E. Szeto, A. Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum 2017; 30(2):111-116.

4. Time to Change. Stigma shout: service user and carer experiences of stigma and discrimination. 2008. (http://www.time-to-change.org.uk/sites/default/files/Stigma%20Shout.pdf).

5. Burra, P. Kalin, R. Leichner, P. Waldron, JJ. Handforth, JR. Jarrett, FJ. Amara, IB. The ATP 30-a scale for measuring medical students' attitudes to psychiatry. Medical Education 1982;16(1):31-8.

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Conflict of interest: None declared

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